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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change c"dit )(PROG4) revised 5/23/94 <br /> FACILITY ID t{ U C G FACILITY NAME Pn V+ p5 PC� CO v Y0 0-5-7- <br /> RECORD ID # S S3 PRIOR DIST # PRIOR SWEEPS # <br /> 1111 <br /> Site Mitigation: vironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency SiteAgency: �WQCB DISC EPA L Site �ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # 6 Z 1 4:-( 7 PROGRAM ELEMENT # Z $�/ CURRENT STATUS <br /> NUMBER OF UNITS EPA ID N: INSPECTION CODE <br /> Number of TA.'1KS linked to this PROGRAM record <br /> BILLING AC)VOWLEDGE.'1(ENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record information Form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Awunt Amount Paid Date of Payment Payment Type Receipt 4 Check N Recvd By <br />